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Out-Of-Network Insurance Coverage Denial Lawyer

Was Your Medical Insurance Claim Denied for Being Out-of-Network?

Gianelli & Morris is Here to Help

Health insurance companies like to be in control. They want to be able to tell you what medical services you can receive, when you can receive them, and from which medical care providers you can receive those services. By controlling your health care options, the insurer can maximize its profits and minimize its payments. Many health insurance companies will flat out refuse coverage for medical treatment provided by physicians outside of their established network.

If your insurance claim was denied on the grounds that your care provider was outside the network, you might have grounds for appeal. The insurance claim denial attorneys at Gianelli & Morris are ready to help you get the medical care you need without going bankrupt in the process.

What is Out-of-Network Coverage?

Every health insurance provider in California has an established network of medical offices, hospitals, and other healthcare providers. These are medical care providers with which the insurance company has an established business relationship. Insurance carriers and in-network healthcare providers typically have an established contract for services, often at a reduced rate. Policyholders can obtain medical care from these providers in accordance with the insurance policy and seek reimbursement for those visits.

Many insurance providers require policyholders to seek care from healthcare providers within their established network to obtain coverage. Patients, unfortunately, are not typically free to choose any doctor that suits their needs; they must often choose from a smaller list of physicians covered by the specific insurer and policy. If the patient obtains medical care from a doctor outside of the insurer’s network, the insurer may try to pay a reduced rate for the treatment or refuse coverage entirely. This often occurs as a result of an emergency: A policyholder is visiting a family member in another state when they suddenly wind up in a car crash and need medical help from a local hospital.

Insurers prefer to avoid out-of-network providers because they do not have an established business relationship. Often, the provider is out-of-network precisely because they have not agreed to provide services at a reduced rate. Insurers may also prefer to curate a smaller list of providers in order to have more bargaining power and to have assurance regarding the quality of services. However, just because you need medical help from an out-of-network provider does not mean your insurer can deny you coverage in all instances.

When Should Out-of-Network Claims be Covered?

There are circumstances under which insurers should pay for medical services, regardless of whether the healthcare provider is within or outside the network. In a variety of situations, patients need medical care that is not available from in-network providers. Circumstances under which insurers should pay for care regardless of whether a care provider is within the network include:

  • Emergency services. If a policyholder must obtain urgent care due to an accident or other emergency, they may not have the time or capacity to pick an in-network provider. The patient may be located out of state or in some other situation where waiting for an identified in-network provider is not practicable or safe. Most insurers make an exception for emergency medical services.
  • Specialized care. Insurers may have a limited range of medical providers within the network. If a policyholder needs specialized care not provided by any in-network doctors, then the patient must go outside the network to obtain treatment. For example, a policyholder may need a special type of heart surgery that no in-network doctor is qualified to perform. In such cases, policyholders can seek pre-approval from the insurer to obtain out-of-network treatment and still secure reimbursement. Often, the insurer will require the policyholder to first obtain a referral from an in-network doctor. If the insurer refuses to approve an out-of-network treatment that you need out of medical necessity, you might have grounds for an appeal based on the insurer’s legal duties.
  • Pre-existing relationships with a doctor. Many insurers will allow patients to continue receiving treatment from a doctor with whom they have a pre-existing relationship, so long as the policyholder has pre-approval from the insurer. You might need to identify your existing physician at the time you apply for your insurance coverage, or at least in advance of obtaining treatment while covered by the plan.

Call Gianelli & Morris for Help with a Health Insurance Coverage Denial

If your insurance claim has been rejected because the provider was allegedly outside of your coverage network, you do not have to accept the rejection at face value.  An experienced and effective insurance claim denial attorney can help you fight back against a wrongful denial and ensure health insurance companies are held accountable for their mistakes.  We help injured Californians with all manner of insurance denials and denial appeals, whatever the stated justification.

If you are ill or injured and you need help pursuing a claim with your insurance provider, or if you have been the victim of bad faith insurance conduct committed by any California insurance company, contact the professional and detail-oriented Los Angeles insurance denial lawyers at Gianelli & Morris for a no-cost evaluation of your claim at 213-489-1600.

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